Management of the aggressive emergency department patient: non-pharmacological perspectives and evidence base.

INTRODUCTION: Aggression in the Emergency Department (ED) remains an ongoing issue, described as reaching epidemic proportions, with an impact on staff recruitment, retention, and ability to provide quality care. Most literature has focused on the definition (or lack of) core concepts, efforts to quantify the phenomenon or provide an epidemiological profile. Relatively little offers evidence-based interventions or evaluations of the same. AIM: To identify the range of suggested practices and the evidence base for currently recommended actions relating to the management of the aggressive Emergency Department patient. METHODS: A meta-synthesis of existing reviews of violence and aggression in the acute health-care setting, including management of the aggressive patient, was undertaken. This provided the context for critical consideration of the management of this patient group in the ED and implications for clinical practice. RESULTS: An initial outline of issues was followed by a systematic search and 15 reviews were further assessed. Commonly identified interventions are grouped around educational, interpersonal, environmental, and physical responses. These actions can be focused in terms of overall responses to the wider issues of violence and aggression, targeted at the pre-event, event, or post-event phase in terms of strategies; however, there is a very limited evidence base to show the effectiveness of strategies suggested. CLINICAL IMPLICATIONS: The lack of evidence-based intervention strategies leaves clinicians in a difficult situation, often enacting practices based on anecdote rather than evidence. Local solutions to local problems are occurring in a pragmatic manner, but there needs to be clarification and integration of workable processes for evaluating and disseminating best practice. CONCLUSION: There is limited evidence reporting on interventional studies, in addition to identification of the need for high quality longitudinal and evaluation studies to determine the efficacy of those responses that have been identified.

Violence and aggression in the emergency department is under-reported and under-appreciated.

AIM: To examine levels of reporting of violence and aggression within a tertiary level emergency department in New Zealand, and to explore staff attitudes to violence and reporting. METHOD: A one-month intensive, prospective audit of the emergency department's violence and aggression reporting was undertaken and compared with previously reported data. RESULTS: There was a significant mismatch between the number of events identified during the campaign month and previously reported instances of violence and aggression. The findings identified that failure to report acts of violence was common. CONCLUSIONS: Reports of violence and aggression in the emergency department underestimate the true incidence. Failure to report has potential impacts on organisational recognition of risk and the ability to develop appropriate policy responses.